Transcript

0:10

This morning, are with us. So quick quick background, Jacqueline is, she is a certified athletic therapist from Canada and also or from from Vancouver, Canada originally. She she obtained her athletic therapy degree from Sheridan College in 2011. And in 2014, she moved south and went to University of Utah, had a master master of exercise in sports science, and has also had the opportunity over those years to work a variety of populations in youth sports. I've worked with Canadian Football League, work with those those athletes.

0:50

Also, with Cirque du Soleil, And then, she is had her emergency first responder emergency, medical responder certificates in EMT, a nationally registered EMT credentialed. And then, currently, she is, currently working her doctor doctoral degree at Oklahoma State University Health Center in in health for health sciences in Tulsa, Oklahoma. She works with their athletic training master of science in athletic training program. And one of the things that she's doing a lot in is really is getting it deep diving into research into looking at factors of knowledge decay in emergency management. So this is where, we were taught we had a conversation doing you know, not long ago, and I'm like, okay.

1:38

You've done some great stuff, and we wanna get her on the call, as a clinician and bring bring up some really good information. And on this topic is on decompensation and shock. And what to look you know, we think about the decompensating athlete, what it looks like. We've talked about that already in a couple of of other sessions. So with that, Jacqueline, I'm gonna turn this over to you.

1:58

It's a pleasure to have you here this morning.

2:00

Perfect. Thank you so much. Can you see what I see? Can you see a screen? Everything?

2:04

Okay. Perfect. Karen said earlier that she is not very technologically advanced and neither am I. So this is my first webinar giving my first webinar, so we'll see we'll see how it goes. So far, I think I've managed to do all the things.

2:18

You're you're back.

2:18

Thank you so much for having me. I'm super excited to talk about this topic. I love emergency management. I'm so passionate about it. Obviously, I'm that's what I'm doing my research in.

2:29

And so we're gonna talk about shock. And I think, oh, first of all, I have no conflict of interest, no disclosures for anything. I think the way that this day has been planned has been excellent because we've already started to talk about it. Karen and Caitlin have touched on a couple of the what ifs. Right?

2:48

So they've talked about asthma, and they've talked about hyperventilation. And then it's the, okay, but what ifs? And so that's where this decompensation will come in a little bit. So, learning objectives, we're gonna identify some key signs, in decompensating athletes. We're gonna assess and prioritize these signs, and we're gonna apply OPQRST and sample, which are obviously been talked about a lot today, which is fantastic.

3:15

So maybe we'll be able to catch up a little bit on time here. So shock. What is shock? Right? Shock is a clinical syndrome or a state of collapse.

3:25

It's when your system collapses, and it it has varying levels. Right? So you can have kinda baby shock is what I tell my athletes. You know, as soon as you have that insult or injury, you start experiencing some form of shock. And initially, your body systems are gonna be able to compensate for that.

3:45

They're gonna be able to compensate for something that happens to the pump, the tubes, or the fluid that makes up this system. And so our bodies are really great at dealing with that and knowing what's gonna happen and and being able to, increase our heart rate, increase our breathing rate, being able to make sure that everything is getting where it needs to get. But, eventually, that insult or injury becomes too great and the pump, the tubes, and the fluid is gonna fail somewhere, and our bodies are not able to compensate for that. And that is where we need to recognize the signs of going into that decompensation, be able to recognize that early early enough so that we can step in and make a change and have a treatment so that we don't go all the way into full decompensation. So, initially, like I said, you're gonna be able to compensate.

4:37

When you do your scene size up or even your primary survey, things might look okay. But as you get into that secondary survey, as you get into your sample OPQRST, things might start to change a little bit, and so it's really important to know the signs and symptoms of decompensation so you can recognize what, decompensation looks like and that you are heading down a slippery slope. And so the key here is just to reassess. So the tools that we have, we've gone through these already today, Seeing survey primary, secondary, and then that ongoing assessment. So what are we looking for?

5:14

Right? The biggest one, the one that's in the top left hand there is altered mental status, confusion, agitation, or anxiety. So that's a lot of things. Altered mental status to you if you don't know an athlete. Let's say you're doing a PRN event and somebody appears to be having a personal situation somewhere else, you might not recognize that as a sign or a symptom of a decompensating athlete, but that's because you might not know that athlete.

5:42

And the athletes that you know and spend all your time with, you're gonna be able to pick that up pretty quickly. But anxiety could be something from hyperventilation, like Caitlin talked about, or they could be sliding down that slope really quickly. So it's something to keep an eye out for. Cool camp clammy pale skin. If we have athletes that are participating in sport, even if it's chilly outside, they should not be cool, clammy, and pale.

6:05

Right? That's just that's not gonna happen. Rapid shallow breathing. Well, if you're exercising, that might be your breathing rate. However, when you stop, your body should also be able to regulate that.

6:17

Right? And that should return to normal fairly quickly. So if you're into your secondary reassessment type of scenario and they're still having that as a sign and symptom, you it a little red flag should be going off somewhere like, hey. I need to pay attention to this. Right?

6:30

Rapid weak pulse, nausea or vomiting, weakness, thirst. Right? That goes with that anxiety mechanism. Oh, I'm so thirsty. I'm so thirsty.

6:38

Right? Something just to kind of keep an eye out for. Decreased blood pressure, cyanosis, inability to balance, fainting, altered LOC, all of those things, they're kind of your big ticket items. If you're gonna start having all of those, you are at the point where this athlete or this patient has decompensated and you need to get extra medical help regardless if if you're dual, EMT, paramedic, BLS, whatever you have, ATC, obviously, you're probably gonna need some outside help. That means that that athlete or patient has to the point where they really are gonna need some extra help.

7:15

So just keep this slide in mind as we kind of go through the rest of it here. So for your scene size up, look for your big picture items. Right? Look for that original or that initial altered mental status That's gonna take you if you're thinking of a decision tree in your head. What was the mechanism am I dealing with, a TBI here?

7:35

Concussion maybe, or does it have nothing to do with the head, neck, or spine, and this could be something internal, something that this athlete is decompensating. Pools of blood. Right? That's obviously a tube fluid issue that needs to be fixed rather quickly. And as, we just learned in that last scenario, we learn how to deal with that very quickly, and that's fantastic.

8:01

But at the same time, recognizing that that decompensation is starting to happen at the same time. So, yes, I'm dealing with this CAB injury, but I need to keep in the back of my mind how much blood is going to be lost before they can't compensate anymore. And so if you're not familiar, the MAR method is an excellent super easy way to, guesstimate, blood loss. It's m a r, the m a r method, MAR method. So take a look that up if you are unfamiliar with it.

8:33

It's fantastic, super easy to use. Any allergens. Right? So we talked about asthmatics and pollen. That can be an allergen when you, you know, go to your car in the morning and it just looks totally green with pollen.

8:46

Okay. You need to be thinking about those athletes. Look for do a quick scan for a medical alert bracelet. Look for drug paraphernalia. Right?

8:54

You never know what you're gonna come across. Right? Hysterical bystanders. If you are coming across a scene and there is a hysterical bystander and then there's someone else lying on the ground, something has happened here. And you your patient might be the patient lying on the ground, but it also might be the hysterical bystander who can't really control their emotions or what they're doing anymore.

9:17

So you can kind of have a dual situation there. Right? So what is your general impression of the scene? K? And as we talked about a couple slides ago, decompensation at this point might not be clearly evident or might not be present yet.

9:31

They're still kind of compensating. They're kind of right on that grayish line before they go down the slippery slope. Right? So this is just an example. What happens if your athlete at the end of the bench does not jump up to celebrate a game winning 3 point shot at the buzzer and appears maybe dazed and confused?

9:47

So think about that in the back of your head. You know? If this is a youth tournament situation, maybe they've played 4 basketball games that day. Maybe it's a collegiate setting, and they got elbowed under the ribs and didn't tell you about it at the beginning of the game, and now it's 2 hours later. Right?

10:04

There could be internal bleeding there that they were able to compensate for originally, but now they can't, And they haven't told you. So although this is your scene size up moment, this injury or illness, this insult has been going on for a couple hours. Right? Things like that to think about. So just getting that general impression kind of from afar.

10:27

Going into your primary assessment, and it's been said three times today because there's been 3 other people speaking. Trust your process. Right? Your ABCs or CABs, your level of conscious and mental status, your head to toe. And I wanna touch on DCAPBTLS here.

10:43

And so DCAPBTLS, if you're not familiar with that acronym, I didn't spell it out, But it's deformities, effusions, crepitus, abr abrasions, punctures, burns, tenderness, lacerations, swelling are the big ones, but a lot of those letters have 3 other things that they'll stand for as well. And so that's doing a quick visual scan on that primary assessment. Like, I'm looking at this athlete or patient. I'm looking. If they're standing up, then their pump is still working.

11:15

If they're not spreading blood, then their tubes appear to be working. They look to have fluid in them, so then what's the problem? Right? What is the problem if they don't feel well? If they don't look well, where is that problem?

11:28

And so that might help you. You might see some bruising somewhere. You might see some random swelling somewhere, and that can help you kind of determine where within the pump tubes fluid situation that problem is coming from. And then as you do your, primary assessment, compare your values to what you're assessing or compare your expected values to what you're assessing in real time. I talked about it a couple slides ago.

11:56

What happens if their rapid breathing and their heart rate is elevated because they just walked off of the playing surface? Now it's 7 minutes later. They should be if they're an in shape person, right, if they're an in shape human being, those levels should kinda come down a bit. There's that that the body is gonna self regulate, and they're gonna kind of come come down from that physical activity. If that's not happening, why?

12:22

Right? Why are your values that you're getting not kind of clicking or syncing up with the values that you're thinking in your head? Right? Can they add can they answer your questions? If they can't answer your questions and they're altered, why are they altered if they don't have a mechanism that matches?

12:40

And that's something to kind of think about. And, again, it just goes back to, those situations where you just or you're just thinking why. Why is this here? We always want to find the cause and treat the cause, and that's just I appreciate it to my students all the time, but find the cause, treat the cause, Especially with when you have an athlete that's decompensating, you don't know the why, and so you need to dig to find the cause. Challenging high pressure environments, obviously.

13:11

Caitlin mentioned it, and I think Karen talk touched on it as well. The more you do it, the easier it's gonna be to become automatic when you have to do it. So if you are reciting ABC's, LOC, DCAPBTLS, OPQRST sample in your head and you're practicing that method with everything you do, even if it's a simple, maybe an ankle assessment or whatever, it's just been become more and more automatic for you so that when you're in that high pressure environment, it just comes out, and it's automatic. You don't have to think about, and it's that's just the way to do it, and I think Ronnie said it as well. So when you're practicing either with your coworkers, with your peers, with your teams, with your coaches, just making sure that you're leading them through, this is what my primary assessment looks like.

13:58

This is what I'm gonna focus on. These are the questions that I need answered to be able to get to my end goal. Moving on to your secondary, assessment. So altered mental status and, a decreased level of consciousness is a telltale sign of shock, but if you so if you cannot sample them, if you cannot OPQRST them, if you cannot an ask them a question, then you're not gonna get any of the answers that you need to be able to find your cause and treat your cause. Right?

14:33

So if that's already happening, you're you're gonna need to call for some assistance, and you can sample an OPQRST your bystanders. Never forget about your bystanders, teammates, coaches, managers, all of those people are great for you to have in your pocket. They can usually answer all of the questions of, hey. What happened to this person today for you, which is huge? You can treat for shock while you are performing your secondary survey.

15:01

And so treating for shock is laying them down on a flat surface. I use the analogy of a half empty water bottle, and I don't have one. Oh, I do have one. Okay. So a half empty water bottle.

15:13

Right? Oh, there we go. Half empty water bottle. Right? So if this is your brain and this is your fluid, it's not getting to your brain.

15:20

If you lie them down, it evens out. It flattens out. It's able to get to all the things that it needs to get to. So lie them down, assess them supine or in their recovery position, and keep going. Right?

15:32

You still have to find the cause so you can treat the cause. And so the way that you're gonna do that is you're gonna use your sample in your OPQRSD. So we've talked about it at length, and so think about how those answers might change when you have someone that's decompensating. When you have someone who is not satting at the level that you want them to. Their oxygenation is now at, like, a 94, maybe a 92.

15:59

Let's get some oxygen on them while they're lying supine. Let's treat for shock while we're still ascertaining what is happening here. Right? Sorry. I lost my train of thought.

16:12

Looking for red flags. Right? Yes. Sample. The s is stands for signs and symptoms, but it also can stand for subjective.

16:21

What the heck happened to you? Right? What happened? I don't I think sometimes we get so focused on signs and symptoms. If we had asked our basketball player that didn't wanna get up at the end of the game, hey.

16:33

Like, what happened? They might volunteer to you that, oh, yeah. I did get elbowed earlier in the game, and I just haven't been feeling right since then. Perfect. Right?

16:42

Now okay. What's happening inside of you now? I can direct more of my sample and my OPQRST questions towards what it is I really wanna find out. It's okay to guide, your patient a little bit towards what you kind of are thinking. Right?

16:60

If they're gonna start talking about the great sandwich they had for lunch, you had a sandwich, that is all I need to know. Were you allergic to anything in the sandwich? No? Cool. Let's move on.

17:09

Right? So making sure if if they're just gonna go on a tangent about a sandwich, that might be their altered mental status coming into play. So it's just always thinking about the horses and about the zebras. Medications. When you ask a medication question, are you on any medication?

17:27

With respect decompensation, if they say yes, your question is, did you take them today as prescribed? If they say no, your question should be, but are you supposed to take any? Right? Because if they're not gonna take that daily medication for whatever reason a high schooler thinks they don't need their medication on whatever day, that might be one of the reasons why they're decompensating so quickly. Maybe that medication is essential to life for them, and they've just decided on this random Thursday that it's not in their cards for the day.

18:03

Right? Have they taken a dose? Have they not taken it at all? Did they miss a dose? What is happening there?

18:10

Making sure that you're really probing into those questions, especially with diabetics, asthmatics. Very, very important to make sure that you're kind of really digging in on those questions. Last oral intake, did they eat anything? Do they feel like they could eat anything now? Right?

18:30

If they're super, super thirsty now, ask a little bit more about that thirst. Right? That's related to anxiety. That's their body decompensating and telling them that they're thirsty because thirst is a mechanism to increase the fluid volume. So there's fluid being lost somewhere that's prompting that thirst mechanism and telling it to increase.

18:50

Increase my volume. Increase my volume. Why are you so thirsty all of a sudden? Where are you losing volume internally that I need to be worried about? Right?

19:02

And so those are just some sample things that I wanted to highlight. Within OPQRST, decompensation can occur quickly. I don't know if I've said that exact sentence, but I'll say it again. Decompensation can occur quickly. They can be fine talking to you, everything is great, and all of a sudden, they hit that certain threshold, which obviously is different in everyone.

19:24

Otherwise, we wouldn't have jobs, and it just happens. It's very fast. So that onset could be, oh, I haven't been feeling great for 2 hours, 4 days, however long. I had a lacrosse coach once who just looked yellow to me, and he'd kind of been off for a couple weeks, and I finally sat him down. I said, you do not look well.

19:46

Tell me about your last couple weeks. It turns out he had had just a spontaneous intestinal perf, and he was he went to the hospital. He had 4 complete blood transfusions, and he was in the hospital for 22 days. And so you never know that onset question can be a half an hour discussion if it needs to be. And so really, really kinda delving into how long have you not been feeling well.

20:12

General malaise, if we're dealing with an athletic population, just the general human population, you should feel pretty good most days. So if you haven't, what's happening and how close are you to that slope? Another, important one is the region of pain or region of symptoms or where does these symptoms radiate. Some sort of dull aching or some sort of throbbing, that's really not supposed to happen. You're not your body is not really supposed to throb.

20:44

It's not really supposed to ache. Right? You're gonna have the morning aches and pains and the after the long run aches and pains, but you really shouldn't ache all the time. And so if somebody, in that line of questioning, you know, oh, this is really achy or something wakes me up at night, think that that decompensation, maybe that's happening. And, again, it can happen.

21:06

It happens fast once it happens, but it can happen from an acute injury from a now. It can also happen from something that happened a while ago. So it's important just to really, kind of think all of the things in your head at the same time. Severity with respect to OPQRST and a pain scale. If somebody is a 10 out of 10 pain, they're probably not decompensating, just as an FYI.

21:32

If their body is still able to feel severe pain and they're still able to scream and hoot and holler, they're they're doing okay. It's when they get really quiet that that red flag should start to go, and you really think, okay. Their mental status, their body is trying to conserve energy. What is happening here? Why are they getting so quiet?

21:52

Why are they getting so tired? Why are they getting so sleepy? They don't want to do anything. And so that's something to kind of keep in mind with that. Oh, no.

22:03

Advance. Oh, nailed it. Oh, didn't even know I had that slide. There we go. Okay.

22:09

Vitals. So I think I've said it 6 times, but altered mental status, altered level of consciousness, that's your most important vital sign for them for you to know, like, hey. They are on the way out. That's the first thing that's kinda gonna go. Skin color and temperature, you don't want them to be cool and clammy like Karen said.

22:26

You might not have a BP cuff. You might not have a pulse ox. So you can do a skin check. You can take a respiratory rate. You can take an old school heart rate, radial pulse.

22:34

Right? Those things are gonna tell you what you need to know. Once that VP starts to dive, you know that you are in the presence of someone that is decompensating. Same thing with their heart rate, respiratory rate, pulse ox. Their respiratory rate is gonna shoot up to try to sat them.

22:51

Their heart rate is gonna go up initially, then it's gonna go down. Their pulse ox could be all over the place. You never know when that pulse ox is kinda gonna shoot up and down. It's gonna be obviously related to respiratory rate. So just assessing once and then assessing again.

23:07

That reassessment is key here because they could be fine, could be fine, could be fine, and then all of a sudden, they're just gonna compensate. So essential reassessment. So this is essential in the diagnosis of shock, any shock, even the beginning stages of shock. Right? And then as they decompensate, it's even more important so that you're able to catch that and you're able to see the trend.

23:33

So in a critical patient, we like to reassess every 5 minutes. And in a noncritical patient, it's okay to reassess every 10 to 15. If you see a huge difference in your first reassessment between your vitals, your, hey. What happened? Your, hey.

23:48

Talk to me's. In those first 10 minutes, you need to think about, okay. I need to reassess this person every 5 minutes, every 3 minutes because they might be on that slope on the way down to decompensation. So your vitals are gonna help you where they are in that shop continuum. I think it's important to say that once they're on that slope down, there's not a whole lot that we can do on the sideline on the playing surface to bring them back.

24:17

Unless you're able to throw in a line, an IV, and open it up wide and potentially give them an airway adjunct. You might have to breathe for them. Things can go very bad very quickly, so you are gonna need to ask for additional help and or transport efficiently with respect to the fact that you're all the way in decompensation. But you can treat for shock the best way you can. So you can give them oxygen.

24:42

You can have them lie down supine so that their fluid is able to reach all the important bits, all of those things. But recognition of shock is truly, truly your their best chance for recovery and finding the cause and treating the cause. So as soon as you can recognize it, figure out what is causing it, try to treat that cause, fix that cause, find and fix, that is really gonna help you in understanding how the athlete got to the where they're getting and what you need to do to get them out of it. Right? If they are an alter with they have altered mental status or an alter lower LOC, they might not be able to eat or drink anything.

25:23

They might not be able to quench that thirst mechanism. Right? So we are gonna have to give them fluids somehow. A lot of states, you're able to do IVs now, but if you haven't been trained in it, then you're obviously not gonna do that. So you're gonna need external help with that.

25:39

And so, again, finding the cause, treating the cause is really the biggest the biggest aspect for shock when it comes to that. So that's all I've got for now. Thanks, Karen and Caitlin, for going through sample and OPQRST for me. That was fantastic.

25:59

Fantastic wrap up, today. So, let me do one thing. Let's see here. That was a a great, ending session there, Jacqueline. That was, you know, it really encapsulates very easily.

26:14

I mean, this is a just so you all know, this is a deep topic. I mean and to get this the nuts and bolts of it, I mean, we could go on for several hours of different different topics, subtopics related to shock and decompensation. I think the one couple things that I, you know, the I see with this, and I know you've seen that everyone else in the audience think they see as well is, you know, you have a problem. You recognize it. You treat it.

26:39

Move through there. And then for the most part, the of the of the spectrum of conditions that we see, there you have very there's not many you have a a small toolkit that you can treat the majority of these things. You know? If it's altered mental status, knowing what the condition are they hypoglycemic? You need ox you know, air oxygen.

27:03

You know? They're they're decompensating. Or if they've had a trauma, you can recognize what that problem is. I know I was this past weekend, I was up at the Boston Marathon and, you know, I would work in ICU area. So they come in and our you know, we know that they have we know what the problem is.

27:20

So if they came in and they had an altered mental status, that is the red flag. We need to automatically know that we're going to do the first thing we're doing if they come into ICU, we're we're doing a core temp. So when you see 25 plus heat strokes, you know, in a it's running through, and they're getting them over to heat deck, or they're coming back to us as well. It's just the the other thing that I think that, what you mentioned I'd like to hear your perspective on this is that you know, you mentioned, okay. If they're getting they're either getting worse or they get better.

28:03

And the one thing I see is, is this you mentioned the red flag is if they get better to a point, but they stop. I give an example of, like, heart rate. You know, the normal heart rate response, if they've had exertion, etcetera, they're looking better. They're talking, but they're con they're just they're you know, after 20 minutes, if their heart rate is still 85 or 90, they are

28:29

they're They're not doing well.

28:31

They're not they're decompensated. They're still they just they're just kinda hanging around for the for they're trying to hang around, and it's not working well. So you have to recognize that that is and that's in any setting, a football player or basketball. You know, they've been exercising. Look at the context.

28:51

Yeah. What so I'd like to hear your your thoughts on that just kinda, you know, what you've seen as well.

28:57

Absolutely. I think definitely. That's where that reassessment really comes in, and there was a line that said, compare what you are assessing to an expected value. There's a reason that we have the knowledge of what those normal values are. There's a reason those exist.

29:17

There's a reason that we are taught those values. It's so that we can compare an assessed value back to those normal values. Because within 20 minutes of stopping physical activity, you should be at normal. Like, you absolutely your expected and your average your, like, population average values should be the same to what you are assessing. And if they're not, why?

29:43

Why is this person having such a hard time recovering? Right? And maybe 5 plus or minus 5, right, on a heart rate if we're talking heart rate. Fine. Whatever.

29:53

But if you're still at 85 to a 100 just sitting, talking, that's really high. Right? And so why is that? That's where your sample really you're gonna need to sample them again. And I think important too is people don't intend to lie.

30:10

Right? They don't intend to forget. But just because you sample them one time at the beginning of your assessment, doesn't mean that you can't sample them again. Keep asking those questions because we all know we've all worked with kids. The story changes as you keep asking those questions, and so it's okay to resample them.

30:27

When you do that reassessment, redo that whole secondary assessment, making sure you didn't miss anything as the clinician because they are going to selectively forget half of what they've told you anyways. So I think I think that's a really good point, Ray, to make sure that you're understanding that you're not missing anything and and really comparing. And they can compensate to a point, and then it's just when are they gonna kinda let go? When are they not gonna be able to maintain that compensation?

30:54

Right. Or the intervention you have is not working. I mean, that's the other I didn't mention you hit on that as well. We've hit on that already that, in other situations like you know, I use the example. An easy example, I think, that most people can see is, okay.

31:05

Let's say you have a possible, like, a lower leg fracture. Yeah. Well, you know it's gonna be painful. And you know that you if you're if you don't have limited reading, you may have a SAM splint. Like, an EMS puts a SAM splint on, and it's so they do the initial, you know, PMS.

31:21

They're doing the assessment. They apply it. It's gonna be painful. But if it continues to get worse, it means that intervention is not it's not effect. It's either it's applied incorrectly or you need to something else is going on.

31:34

If they keep going up like you just had that that you know, they're showing in a 5, and then 15 minutes later, they are at 8:10, then, okay, we need a red flag some things as well. So those are you know, it was just a couple really good points I wanna thank you for. It makes you know, you did that and emphasize that. I think it's just really just a common sense stuff that we do in in emergency medicine we all do. It's just nice to hear that all it's all you you never can hear it again.

31:59

Absolutely.

31:60

And I think too sometimes the common sense stuff that, like, our intuition, sometimes the science brain takes over and you do you forget to listen to your common sense side, you forget to listen to your intuition, but listen, you know, listen to it. Like, think about the old wives' tale and what your grandmother would tell you if right? Sometimes, when someone says something, you think to yourself, that just doesn't sound right. That can sometimes be a huge cause of some sort of something that is going on internally. Because this decompensation and shock and your bigger kinda general illness y type stuff isn't always due to an injury.

32:41

It's due to an insult to the body that is going to eventually cause a collapse of the system. It doesn't have to be that day, and that's something with shock, the example of the lacrosse coach, it was not that day. It just happened, and it happened over time. And it's just something to be aware of and one of those things to look out for amongst your participants or amongst your, athletes, right, amongst the people that you're hanging out with, essentially doing your job every day. It's just important to get to know them so that you can understand that side of it.

33:14

Yep. I like to, use that as I guess, use a quick analogy or kind of a joke analogy. If it if it walks like a duck and quacks like a duck but eats

33:24

like a

33:24

horse, there's something wrong. You know? So you gotta just gotta use that with mine. So, with that, I'm gonna, we we have, out of time today. Jacqueline, thank you so much for participating.